Article

Surgical Treatment of Osteomyelitis

REOrthopaedics, Inc., San Diego, CA, USA.
Plastic and Reconstructive Surgery (Impact Factor: 3.33). 01/2011; 127 Suppl 1(1):190S-204S. DOI: 10.1097/PRS.0b013e3182025070
Source: PubMed

ABSTRACT Chronic osteomyelitis is refractory to nonsurgical treatment due to a resilient, infective nidus that harbors sessile, matrix-protected pathogens bound to substrate surfaces within the wound. Curative treatment mandates physical (surgical) removal of the biofilm colony, adjunctive use of antibiotics to eliminate residual phenotypes, and efforts to optimize the host response throughout therapy. Patient selection, therapeutic options, and the treatment format are determined by the Cierny/Mader staging system, while reconstruction is governed by the integrity/stability of the affected bone(s) and quality/quantity parameters of the soft-tissue envelope.

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    ABSTRACT: Background: Chronic osteomyelitis continues to be an intractable disease in orthopaedic surgery. Systemic antibiotics and debridement are currently the therapeutic mainstays. Calcium sulphate impregnated with antibiotics is commonly used to eradicate bone infection although there are few reports of its use. Methods: We treated 14 patients with chronic osteomyelitis using surgical debridement, a myocutaneous flap, systemic antibiotics, and vancomycin-loaded calcium sulphate, 12 males and 2 females, with an average age of 47 years (range: 17 to 65 years). In our study, 200 mg to 1000 mg of vancomycin was mixed with 5 cc of calcium sulphate and administered locally at the time of surgery. Tissue cultures were also taken at the same time. Vancomycin levels were determined in the drainage fluid after surgery. Fourteen patients with chronic osteomyelitis of the tibia, calcaneus, or ankle were treated for duration of two years and two months. The location and size of the infection was recorded. Subsequently, the patients were followed up clinically. Results: Satisfactory results were achieved in all patients. All cultures finally showed no growth, all wounds healed, and bone healing in 4 to 12 months. The lowest dose of vancomycin used was 200 mg and was associated with drain fluid concentrations of vancomycin that is much higher than the minimum inhibitory concentration (MIC) of treated bacteria. Medical imaging based on X-ray was performed pre- and post-surgery to evaluate surgical success. Conclusions: A myocutaneous flap that is combined with the 200 mg vancomycin-loaded calcium sulphate was an effective treatment for tibia and calcaneus osteomyelitis less than 4 cm in size.
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